MORNING REPORT

28 AGUSTUS 2017

Supervisor :
dr. Yusra Pintaningrum, SpJP, FIHA

By:
Ayu, Bayu, Qisthi
I. IDENTITAS
Nama : Ny. H
Age : 64 yo
Gender : Female
Address : Gerung
Etnic : Sasak
Religion : Islam
Status : Married
Job : Housewife
No. RM : 599359
Opname : 29 November 2017
Evaluate date : 29 November 2017
II. ANAMNESIS
Main problem:chest pain
History of present disease :
• Patient felt chest pain since yesterday. Chest pain was like discomfort
predilection on the left side, radiating to the back. The pain
increasing in the morning and not relieved by rest.
• Patient also felt hard to breath since 5 days ago. Dyspneu and chest
pain increasing when get too much activity.
• Fever (-), nausea (+), vomitting (-), palpitation (+), cold perspiration
(+)
II. ANAMNESIS

History of previous disease:

• Patient had same chest pain since 1 year ago
• History of DM (+) and hypertention (+) →
consume anti-hypertension and anti-DM
II. ANAMNESIS

Family history
• HT (-) DM (-) asthma (-)
• Heart disease (-)
II. ANAMNESIS

Medical history
• she allready take treatment in Gerung GH:
• O2 nasal canul 2 lpm
• RL 16 tpm
• ISDN SL
• Aspilet
• CPG
II. ANAMNESIS

Alergic history
• No alergic history
III. Physical examination
Status Generalis
General condition : moderate
GCS : E4V5M6
Vital Sign
• Blood pressure : 180/90 mmHg
• RR : 24 x/minutes
• HR : 120 x/minutes, ireguler,
• temperature : 36.5 0C
Localis status

Head:
• Expression : normal
• Morphologic and size: normal
• Hair : normal
• Edema : (-)
• Malar rash : (-)
• N. VII Parese : (-)
• Pressure pain : (-)
• Massa : (-)
Eye:
• Simetris
• eyebrow : normal
• Exopthalmus : (-/-)
• Ptosis : (-/-)
• Palpebra edem : (-/-)
• conjungtiva : anemis (-/-), hiperemia (-/-)
• Sclera : ikterik (-/-)
• Pupil : isokor, round, pupil reflex (+/+)
• Cornea : normal
• Lens : normal
• Eyeball movement : normal to all direction
Ear:
• shape: normal, simetris
• Canalis auricularis:
normal
• Tragus pain pressure: (-/-)
• inflammation: (-)
• Hearing function : normal
Nose:
• Simetris
• Septum deviation : (-/-)
• bleeding : (-/-)
• Sekret : (-/-)
Mouth:
• simetris
• lips : sianosis (-), stomatitis
angularis (-), pursed lips
breathing (-)
• gums : bleeding (-)
• tongue: glositis (-), papil atropi
(-), oral hairy leukoplakia (-),
oral candidiasis (-)
• teeth : caries (-)
• Mucosa : dry (-)
Neck:
• stifness: (-)
• Scrofuloderma : (-)
• Limfonode enlargement : (-)
• JVP : normal, 5 + 2 cm
• SCM muscle : aktif (-),
hipertrofi (-)
• Thyroid elanrgment : (-)
Thorax:
Inspection:
• Contraction of the
• Shape of the chest: normal, sternomastoid or other
symmetry accessory muscle (-),
• Respiratory movement: supraclavicular retraction (-)
symmetry • Ictus cordis : ICS VI axilaris
• Delay in movement (-) anterior sinistra
• Trcahea midline (-) Fossa
jugularis : deviation (-)
• Fossa supraclavicularis, fossa
infraclavicularis : symmetry
• Abnormal retraction of the
interspace during inspiration (-)
2. Palpation: 3. Percussion
• Trachea deviation (-) • Percussion notes
Sonor Sonor
• Pressure pain (-),nodules (-),
crepitation (-) Sonor Sonor
Sonor Sonor
• Chest expansion symmetry (+) • lungs-hepar border:
• Tactile fremitus : +|+ Inspiration : ICS VI
+|+ Expiration : ICS IV
+|+ Excursion: 2 ICS
• Ictus cordis : ICS VI linea • lungs-cor border :
axillaris line anterior, thrill (-).
Right : ICS II linea parasternal
dextra
Left : ICS VI linea axillaris line
anterior sinistra
Auscultataion
• Cor : S1 S2 regular, murmur (-) gallop (-)
• Pulmo :
• Breath sounds
Rhochi Wheezing
Right left Right Left Right left
Vesikuler Vesikuler - - - -
Vesikuler Vesikuler - - - -
Vesikuler Vesikuler - - - -
Abdomen

Inspection: Auscultation:
• Distension (-) darm countur (-), • Bowel sounds
darm steifung (-). (+)15x/menit
• skin: scars (-), dilated veins (-), • Metallic sound (-)
rahses (-) spider nevy (-) • Bruits aorta (-)
Percussion: Palpasi:
• Distribution: • Epigastric pain
tympany pressure (-)
+ + + • Abdominal masses (-)
+ + + • Hepar, lien
enlargement (-)
+ + +

• Shifting dullness (-)

Ekstremity

Upper extremity Lower extremity

• Warm akral : +/+ • Warm akral : +/+
• deformity : -/- • deformity : -/-
• Edema : -/- • Edema : -/-
• cyanosis : -/- • cyanosis : -/-
• Ptechia : -/- • Ptechia : -/-
• Clubbing finger : -/- • Clubbing finger : -/-
• CRT : <2 detik • CRT : <2 detik
Resume

• Patient felt chest pain since yesterday. Chest pain was like
discomfort predilection on the left side, radiating to the back.
The pain increasing in the morning and not relieved by rest.
Patient also felt hard to breath since 5 days ago. Dyspneu and
chest pain increasing when get too much activity. Nausea (+),
palpitation (+), cold perspiration (+)
• BP: 180/90 mmHg, T: 36.5 HR: 120x/m iregular RR: 24x/m
• Ictus cordis in linea axylaris anterior sinistra
Assesment

• ACS + HT grade II
Diagnosis Planning

• DL
• Cardiac enzyme
• ECG
• Chest X ray
• Ecocardiography
• CTR > 50%
• Cardiomegaly
IV. Laboratory

Parameter Result Normal range

HGB 11.2 (-) 12,0 – 16,0 g/dL

RBC 4.21 3,5 – 5,0 x 106 /µL
HCT 33.4 (-) 36,0 – 48,0 %
MCV 79.3 80,0 – 100,0 fl
MCH 26.6 26,0 – 34,0 pg
MCHC 33.5 32,0 – 36,0 g/dL
WBC 9.09 4,0 – 10,0 x 103 /µL
PLT 293 150 – 400 x 103 /µL
Parameter Result Normal range

BG 141 < 106 mg/dL

Creatinin 0.9 M: 0.9-1.3 W: 0.6-1.1
Ureum 16 10-50 mg/dL
SGOT 14 < 40 mg/dL
SGPT 17 < 41 mg/dL
CKMB 25 < 16 u/L
Na 136 135-146
K 4.5 4.5
Ca 104 95-108 mmol/L
Therapy Planning

• Oxygen nasal 4 lpm

• IVFD RL 15 tpm
• Pro Trombolitic  Fibrion in 100cc Nacl
• Aspilet 1 x 80mg
• CPG 1 x 75mg
• Simvastatin 20mg ( 0-0-1)
• Inj Novorapide 3 x 8 unit
Acute Coronary
Syndrome
Definitions

Acute coronary syndrome (ACS) refers to a spectrum of clinical

presentations ranging from those for ST-segment elevation
myocardial infarction (STEMI) to presentations found in non–
ST-segment elevation myocardial infarction (NSTEMI) or in
unstable angina. It is almost always associated with rupture of
an atherosclerotic plaque and partial or complete thrombosis
of the infarct-related artery.
Definitions
• Unstable angina:
• An unprovoked or prolonged episode of chest pain
raising suspicion of acute myocardial infarction (AMI)
• Without definite ECG or laboratory evidence
• NSTEMI:
• Chest pain suggestive of AMI
• Non-specific ECG changes (ST depression/T
inversion/normal)
• Laboratory tests showing release of troponins
• STEMI:
• Sustained chest pain suggestive of AMI
• Acute ST elevation or new LBBB

* ALS handbook 6th Edn

Pathophys
Atherosclerosis
• Epithelial injury
• Migration of
monocytes/macro
phages
• LDL lipids
consumed  foam
cells
• Growth factors 
smooth muscle,
collagen,
proteoglycans
• Atheromatous
plaque forms
Clinical features

• Dyspneu  Heart murmurs

 Chest pain  Tachycardia or

bradycardia
 Nausea
 Sweaty
 Palpitations
 Vomiting
 Hypotension or  Acute confusion
hypertension
 Pallor
 Syncope
 Asymptomatic/silent
 Indigestion
 Fever
 Distinguishing features

• SA: • UA: • NSTEMI: • STEMI:

plaque platelet platelet complete
formation adhesion aggregation occlusion

 Precipitated by • At rest or minimal exertion

stress or exertion
• Lasts >20 minutes
 Lasts <20 minutes
 Risk Factors
Modifiable Non-Modifiable
• Smoking • Increasing age
• Obesity • Gender (male)
• Diet • Ethnicity
• Lack of exercise • Family History
• High serum cholesterol
• Hypertension
• Diabetes
 Investigations
Bedside Obs, ECG
Blood FBC, UE, LFT, lipids, cardiac enzymes, amylase, CRP
Imaging CXR
Special Echo, angiography

UA NSTEMI STEMI
Normal troponin Raised troponin Raised troponin
* ECG normal * ST depression * ST elevation
* Possible ST * Can be normal * Hyperacute T
depression * Possible T wave waves
inversion * New LBBB
* T inversion (hours)
* Q waves (days)

* ST elevation is >1mm in limb leads and >2mm in chest leads

Important ECG findings
Management

A Patent
B Oxygen (aim for sats 94-98%), auscultate, RR
C IV access (+/-fluids), HR, BP
D GCS, pupils, cap blood glucose
E Expose
 Common ACS management

• Morphine (5-10mg slow IV injection)

• Oxygen (titrate sats to need)
• Nitrates - GTN spray (400mcg = 1 spray) or tablet
(1mg)
• Aspirin (300mg chewed)

• Plus an antiemetic i.e.

Metoclopramide 10mg IV

* BNF 64
Unstable angina & NSTEMI

• LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux 2.5mg

OD
• Clopidogrel 300mg loading dose
• Beta blocker - atenolol 5mg
• Nitrates – usually IV
• Consider coronary angiography within 72 hr
STEMI

• Percutaneous coronary intervention (Primary PCI)

• ‘Call to balloon time’ of 120 minutes
• Requires clopidogrel 600mg loading dose
• Rescue PCI after failed thrombolysis
• Thrombolysis
• Streptokinase / alteplase / tenecteplase…
• Contraindications
• Clopidogrel 600mg loading dose AND LMWH
Longer-term management

• Continuous ECG monitoring as inpatient/ CCU

• Aspirin 75mg OD (lifelong)
• Clopidogrel 75mg (1 year)
• Beta blocker (1 year - lifelong)
• ACE inhibitor
• Statin
• Modification of risk factors
ACS Complications
Early <72hr Late
• Death • Ventricular wall rupture
• Cardiogenic shock • Valvular regurgitation
• Heart failure • Ventricular aneurysms
• Ventricular arrhythmia • Cardiac tamponade
• Myocardial rupture • Dresslers syndrome
• Thromboembolism • Thromboembolism
THANKYOU